Questions for Atul Gawande

In the January 26, 2009, issue of the magazine, Atul Gawande writes about health-care reform.

Making health-care insurance more available will not make it cheap. Indeed, giving insurance to currently uncovered groups may cause costs to spiral up faster. The real question is: How can costs be controlled so that insurance will be affordable?Robert ScwartzColumbus, Ohio

That’s a whole essay, or even book in itself. To try to boil it down to two sentences, though: We have a system that pays doctors and hospitals set fees for providing services regardless of quality or efficiency (piecework). That has to change. Medicare has a very promising experiment underway in a few regions of the country. It allows hospitals to keep a portion of any savings they generate by reducing waste and overspending. This is the kind of direction we will need to go.

I have read that costs of the Massachusetts health-care plan will increase by as much as fifty-six per cent, depending upon an individual’s income status. The overall costs of the program increased more than $400 million—eighty-five per cent higher than original projections—and Governor Deval Patrick says this is “not sustainable.” What plan have we had in the past that could help guide the rest of our nation through this crisis?Joseph MungaiElgin, Ill.

One major reason the costs have gone up in Massachusetts is that a lot more people have signed up for subsidized coverage than expected, partly because of the recession. But unlike every other state, the state has less than three per cent uninsured despite the downturn. Anyone without coverage can obtain coverage immediately. But as you point out, there are growing pains. We didn’t have enough primary care physicians, for example, to accommodate the sudden surge of people who now could afford primary care. But out-of-pocket health-care expenses have headed in the opposite direction—medical debt appears to be falling. And the total costs of health care in the state have not risen any more than in other states. However, the financial burden has shifted from bankrupting individuals to now threatening to bankrupt the state. Tax revenues have plummeted. So now we have some decisions to make: cut the benefits, raise taxes, or push doctors and hospitals to reduce costs. The reality is that we are all going to have to pitch in. Which is exactly how a decent health system should work.

I’m an emergency physician who had worked with an electronic medical record (EMR) for the past few years and then recently did some part-time work at an Indian Health Service hospital that used a paper record. I was struck by the ease of using a paper chart, where I could write things down and order tests while I was walking from room to room. However, the past medical history and medication record was much more difficult to access with the paper record than the EMR. The EMR is clearly here to stay—but do you think the powers that be have any understanding of the need to get input from grunts in the trenches like me, rather than just from big shots with fancy academic titles?Douglas MigdenSeattle, Wash.

I’m as concerned and fascinated as you are to see how the shift from paper to computer records in health care is implemented. In my hospital, putting in electronic records felt like a huge learning curve. It felt like it doubled the time it took to get through clinic for awhile. And then a few months later, I found I could do most everything better and sometimes faster. But imagining how my physician-parents, who had solo practices in rural Ohio until they retired last year, would have managed their health I.T. stimulus computer—yikes. It reminds me of when the barcode scanners came into the local supermarket when I was growing up. The cashiers hated it. They swore it was faster for them to punch the numbers in. But a year later no one would ever go back.

It’s a small example of path-dependence, really. Switching from paper to computer is revolutionary, a path jump. And the term “EMR” obscures the key matter at hand here. This will change how we in medicine write EVERYTHING down and track ALL our critical information for patients. Getting it right is not just a matter affecting worker-bee doctors. This will be life and death for patients—in bad ways if done wrong, but also in good ways if done right. The program needs to allow for the fact that recordkeeping is done differently everywhere and will need to be changed gradually, with room for mistakes and learning. The demand to spend all the money now and have all physicians everywhere switch their recordkeeping and billing systems in a matter of months, because we have to spend the money now for the sake of the economy, runs straight against that reality. But reality has to win.

After reading about the potential for real healthcare reform in the U.S., do you think real scrutiny or serious ratings on doctors in the U.S. can be achieved or used as a way to remake or improve health care?James SohBrooklyn, New York

Oh, I think there can be real ratings. I’m fascinated to see how the Zagat Guide’s experiments in having patients rate their doctors for service the same way they have consumers rate restaurants works out. (I think there will turn out to be a close relationship between the quality of service and quality of medical care.) But I don’t think very much of this will change how health care really works. The most important transformation going on in health care worldwide, I think, is that the complexity of medical know-how has exceeded the abilities of individuals. Medicine now requires teams of people to work together to prevent and treat disease for patients successfully. Medical schools don’t teach students how to work in teams or how to bring teams to be successful at this work. It requires communication skills and an ability to monitor and improve team performance. Some of this I touched on in a previous article called “The Checklist.” But insurance reform or not, this is the way we have to go.

Given the weaknesses in states’ continuing-medical-education requirements for physicians, the lapses of up to ten years in medical-board recertification, the continuing refusal of physicians with lifetime board certification to submit to maintenance of competency, and the widespread lack of accountability for medical errors, isn’t it time to reform the way physicians do continuing medical education?John JamesHouston, Texas

It does seem strange to decide whether I’m a competent surgeon just on the basis of a written test rather than seeing how I actually operate and make decisions, doesn’t it?

Currently, the most popular places to become informed about where to get the best care are ranking systems, such as U.S. News, which focus on reputation and availability of technologies. This may be helpful for patients with refractory conditions, but this is not helpful for the majority of patients in our country who just need access to quality routine care. Furthermore, these systems do not assess the quality of emergency care. The Centers for Medicare and Medicaid recently started a ranking system, Hospital Compare, which does assess measures of routine care, but many people are not aware of it or misunderstand it. In our free market system where hospitals care deeply about rankings, face financial competition, and behave like for-profit institutions when they’re not—how do we refocus hospitals to care about providing timely access to quality emergency care?Joshua IssermanPhiladelphia, Pennsylvania

One of the most debilitating attributes of our health-care system seems to me just what you’re getting at. We have ridiculously little measurement. (I wrote a whole book, called “Better,” around exactly this subject.) As a result, we have no idea how we’re really doing across the country in health care—and emergency care is just one example. The Treasury and Labor Departments provide real-time, detailed quarterly reports on everything in our economy from employment rates for textile workers to the productivity of computer manufacturers. But we can’t tell you anything about whether people who get surgery, or emergency care for breathing problems, or depression are getting better results today than they did five years ago. After making sure that people can actually get decent care, providing better, more timely measurement is the single most important thing I think we could do in our health-care system.

Do you believe reducing the expectations of the lay public about the promise of universal health care is a professional, moral, or ethical lapse by health-care professionals who undertake such a challenge? How might I advise young health-care leaders to anticipate and cope with their possible guilt? I finally left the health-care field (voluntarily) as a hospital president because I could no longer reconcile what we were able to reasonably do and what the public was expecting.Michael SkinnerSurry, Maine

Well, there’s a core disconnect between our inability as physicians and hospitals to admit to our failures and fallibility and our insistence that the public expects too much. The two go hand in hand. There’s no question this is hard. We have the malpractice system standing as one force that discourages honesty about our failures. But even larger is the guilt and shame you mention. Still, I’m convinced we have far more to gain than lose as physicians and as citizens from transparency about how we really do. And the vast majority of the public is also more understanding of the stresses and uncertainties of this work than we give credit for.

Why isn’t Medicare a model for a path-dependent reform? What do you mean when you say that Medicare “costs about a third more per person”? More per person than what? It so happens that administrative overhead is about four per cent of Medicare costs, while private health care spends fifteen to thirty per cent to have all those insurance forms pushed around.Linda Hunt BeckmanPhiladelphia, Penn.

My comparison on costs was with the Veterans’ health system, which costs less per person. Offering Medicare as an option for people without coverage is very doable—and very different from Medicare-for-all. Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans. It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations—because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.

I would have no objections to a system in which all my patients had Medicare. But getting there is the thing. I took it to be a sign of genuine concern about the idea that the citizens of Oregon—one of our most liberal states—voted down a Medicare-for-all-type referendum a few years ago.

Yet I also took it to be a heartening sign that all other industrial countries achieved universal health coverage despite using vastly different approaches. Single-payer didn’t prove to be the only way to achieve popular and sustainable universal coverage, and that means there’s a real possibility for us.

Your article states, “Medicare allows you to go to almost any private doctor or hospital you like.” But where we live, there is no primary-care physician who will accept new patients on Medicare, leaving many to go to the emergency room or to a local urgent-care practice that does not contract with Medicare. Medicare’s restricted reimbursement thus distorts the system. Recent media coverage has focussed on a growing shortage of primary-care physicians, which must be a result, at least in part, of earnings limitations inherent in stingy reimbursement in arrangements such as Medicare. How would you propose that a future health-care system built on existing arrangements address these issues?Heather MullettHesperus, Colo.

As a subspecialty surgeon in academic practice, I have great concerns that adding on to existing systems, without significant reform, will continue to compromise care for patients, especially children. With reimbursement levels for Medi-Cal so low, I have patients who travel up to eight hours for surgeries that any local general otolaryngologist should be able to perform. However, all those local practitioners refuse to take their insurance. What are your thoughts on how access to care under the existing state and federal coverage could be improved? One thought I have had is to mandate that all physicians take a certain percentage of Medicaid patients. Or better yet, increase reimbursement for Medicaid to at least the level of Medicare. With the system as it is, the financial strain on top institutions such as UCSF, who then see a disproportionate number of “poorly insured” patients, is becoming increasingly untenable.Anna K. MeyerMD Assistant Professor Division of Pediatric Otolaryngology Department of Otolaryngology-Head Neck SurgeryUniversity of California, San Francisco

Medicare does indeed pay doctors less than private insurers—about ten per cent less than costs on average, as I understand it. Medicaid pays even less—about forty per cent less than costs is the number in my head. There’s always been some reliance on making one’s income on the private paying patients. As insurance companies squeezed those payments, some physicians have begun to refuse Medicare payments. I grew up with an unusual form of cross-subsidy. My mother was, for a long time, the only pediatrician in our county that accepted Medicaid and uninsured patients. She made virtually no income as a result, but our family made up for it from the income my father could bring in as a urologist. (It’s a travesty how much more a specialty surgeon can make than a primary physician.)

No matter what system there is, the battles over how much physicians should be paid (by private insurers or public insurers) will continue (as I mentioned in a previous article called “Piecework”). We need to insure that payment under any system is decent enough for patients to find physicians in their communities to see them. But I also think we make good livings as physicians, and we should be willing to spend part of our time seeing the uninsured and others, whatever the pay is. A blanket refusal to see the destitute and struggling deeply troubles me.

We must decrease costs by changing the unhealthy behavior of Americans, better nutrition (more plant-based and less animal-based foods), weight loss and exercise, smoke cessation. These are major determinants of health, disease, and cost. So how do we take a national approach to addressing these fundamental health and cost factors?Robert HansenPalo Cedro, Calif.

I’m not really sure. Every country is struggling with how to change people’s behavior. Smoking cessation is the one area of real success with social change. When it comes to getting people to alter their diets and exercise sufficiently to keep their weight down for the long term (five years or more), however, there’s been no program with any substantial success.

While I do agree with your goals, I think cost reduction is a theme that cannot be overstated in this reform process. The population is living longer and getting older at the same time. Studies (Dartmouth HC Atlas, etc.) have uncovered two very important facts: Health-care costs rise dramatically in the last two years of life, and chronic-care clinical practice, especially for acute episodes, are often NOT what a dying patient wants. Many patients prefer not to have invasive and aggressive procedures, but health-care professionals insist. Also, many elderly prefer to die at home. This is a long way of saying that end-of-life health-care documents like advance directives need to be standardized and implemented electronically so that health-care professionals have access anywhere. Have you considered this important “change” in how end-of-life health care is practiced?Steve McKinneyRoss, Calif.

Interestingly, I’ve not found studies showing that advance directives—even when aggressively instituted—have successfully reduced overall costs. It’s true that we spend about a quarter of Medicare’s dollars on medical care for people in the last six months of life. But the trick is knowing exactly when those last six months are. A few weeks ago, I did a series of three operations over ten days to try to save a woman following the rupture of her colon. Her family and I agonized over the right thing to do. She had advanced directives saying not to prolong matters if things were irreversible. But I wasn’t at all sure things were not irreversible. So we kept going, and only after a tremendous effort and expense did it become clear that the die was cast. At that point, we stopped aggressive measures. She died a day later. The cost was enormous. But should I not have tried? Not long ago, I had a patient in virtually the same circumstance. And he survived. I just saw him in the office a few weeks ago. His smile could fill a room.

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